Provider Demographics
NPI:1861019762
Name:THEODORE, FARADJA
Entity Type:Individual
Prefix:MS
First Name:FARADJA
Middle Name:
Last Name:THEODORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 AVENUE K APT 4D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-4961
Mailing Address - Country:US
Mailing Address - Phone:347-845-3769
Mailing Address - Fax:
Practice Address - Street 1:4211 AVENUE K APT 4D
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-4961
Practice Address - Country:US
Practice Address - Phone:347-845-3769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
DE103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst